Apply for a Program

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If you do not have medical insurance, we have Financial Counselors who can help you apply for a financial assistance program. You will need to fill out a Financial Assistance Application and provide all the required documents. The information you provide will determine which program you may qualify for.

Here is how to apply for a program:

Step 1: Complete a Financial Assistance (FAA) Packet

A completed and signed FAA must be submitted to us before we can determine whether or not a financial assistance program may used to help pay for your health care bills. Locations to Get a Packet.

Applications must be complete to be processed and you must have all of the required documents. Applications that are not finished and/or do not have all the documents are not accepted and will not be processed. FAA Application

Step 2: Provide All Required Documents (link to Document Checklist)

You will need to provide copies of the following documents with your application, including the following:

Proof of identity

Proof of Santa Clara County residency

Proof of US citizenship or U.S. permanent residency

Proof of income

Proof of assets

When you have all your documents, attach them to your completed application and turn them in. See the Document Checklist for a list of the documents you will need.

Step 3: Get All Information to the Patient Access Department

Completed applications with all the required documents can be faxed to SCVHHS at 408-494-7848, or scanned and e-mailed to: HHSVCApp@hhs.sccgov.org.

You may also drop off the completed application and documents in person to: SCVHHS Patient Access Department, 770 South Bascom Avenue, San Jose, CA 95128.

Once received, the packet will be reviewed according to the rules and regulations for each program or agency. Using these rules, the staff will determine if you are eligible for a state program, a county program, a discount, or full financial assistance.